Scaling Root Planing Form

Possible Complications & Risks:

• Increased tooth sensitivity due to possible exposure of crown margins and roots
• After healing and shrinkage of the gum tissues
• Pain, bruising and swelling
• Additional infection in the involved area and elsewhere may later occur
• Further loss of bone and gum tissue may later occur
• Additional periodontal treatment may be necessary if my periodontal condition is determined to be worse than previously thought. I understand that additional periodontal treatment is not covered by the scaling and root planning fee.

The treatment may fail and my condition may worsen making referral to a Periodontist necessary.

I have been informed that failing to treat my periodontal disease could result in an increase in infection, loss of bone tissue, loose teeth and loss of teeth.

Patient Responsibility & Home Care:

I understand the consequences of inadequate home care and agree to accept the responsibility to be co-therapist for this treatment. I have been given instructions to follow and agree to follow the instructions carefully.

I understand that negligence on my part could result in the failure of periodontal treatment. I further understand that no warranty or guarantee has been made relative to the results that may be obtained by this procedure by any staff member or dentist with the Fatemi Family Dentistry, L.L.C.

Informed Consent & Authorization:

I understand this consent form and I acknowledge that the Fatemi Family Dentistry, L.C.C. staff has answered all of my questions related to the scaling and root planning procedure. I give permission to the dental hygienist and/or dentists to perform this procedure for me.